Pan American Health Organization

Access to comprehensive, equitable, and quality health services

  • Introduction
  • Expanding equitable access to comprehensive, quality services
  • Transforming the organization and management of health services through the development of health care models that focus on people and communities
  • Moving towards the design of comprehensive, quality, universal, and progressively expanded health services
  • Prioritizing investment in the first level of care
  • Increasing employment options, especially at the first level of care, with attractive labor conditions and incentives, particularly in underserved areas
  • Improving the availability and rational use of the medicines (including vaccines) and other health technologies
  • Facilitating the empowerment of people and communities so that they are more knowledgeable about their health situation and their rights and obligations and can make informed decisions about their health
  • Conclusions
  • References
  • Full Article
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Introduction

The Region of the Americas remains one of the most inequitable regions in the world, with millions of people lacking access to comprehensive health services ().

The data for the Region indicate that between 2013 and 2014 more than 1.2 million deaths could have been prevented if health systems had offered accessible and timely services of good quality. Moreover, data for Argentina, Brazil, Colombia, and Peru show limited use of preventive health services, with only 15% to 21% of the population reporting at least one preventive care visit per year. The percentage is even smaller among the populations in the lowest income quintiles ().

The people most affected by lack of universal access to health and universal health coverage are those who live in conditions of greatest vulnerability. There continue to be differences between the poorest and richest populations in access to the health services needed to reduce maternal and child mortality and morbidity, and these inequalities have slowed the Region’s progress (). Data on economic inequalities in the coverage of maternal and child health services for Bolivia, Colombia, the Dominican Republic, Haiti, and Peru show that sizeable gaps continue to exist. In Peru, for example, the coverage rate for these services remains much lower for the poorest women, among whom the percentage who give birth in a health care institution is 69%, compared with 99% among the wealthiest women ().

Health care models in the countries of the Region often fail to adequately address the differentiated health needs of individuals and communities. Segmentation and fragmentation of health services, which exist in the majority of the countries of the Region, exacerbate difficulties in access to comprehensive, quality services, and low response capacity at the first level of care and result in inefficiencies. The available data indicate that only half of persons with noncommunicable chronic diseases are diagnosed and that only half of those who are diagnosed receive treatment, which is effective in only 1 of 10 cases (). The rate of hospitalization for conditions that could be managed in an outpatient setting is an indicator that reflects response capacity at the first level of care. Between 2001 and 2009, the hospitalization rate for such conditions in countries of the Region, including Argentina, Colombia, Costa Rica, Ecuador, Mexico, and Paraguay, ranged from 10.8% to 21.6%. Of these conditions, gastrointestinal infections accounted for the largest proportion of hospitalizations in Argentina, Ecuador, and Paraguay (33%, 27%, and 22%, respectively, of all reported cases of avoidable hospitalization). Most maternal deaths in the Region could also be prevented by delivering quality maternal health care services during pregnancy, childbirth, and the postpartum period. Approximately 81% of the maternal deaths in the Americas are attributable to direct causes, including hypertension, hemorrhage, abortion, and sepsis ().

The possibilities for expanding access by strengthening the first level through a primary health care (PHC) approach are hindered by differences in the availability and quality of human resources for health and the composition of the health workforce. For example, 10 countries of the Region have an absolute health worker deficit (fewer than 25 physicians and nurses per 10,000 population) or show severe inequalities between urban and rural areas in availability, which compounds access problems (). Countries such as Bolivia, El Salvador, Panama, Paraguay, and Peru continued to face challenges in both the availability and the distribution of health personnel in 2012 and 2013. Data from some countries in the Region, including Bolivia, Canada, Panama, and the United States, indicate that the availability of physicians in urban areas is as much as 80 percentage points greater than in rural areas ().

Other key challenges that the Region faces in expanding equitable access to health services are related to access to and rational use of medicines and health technologies. Progress in this area is very much influenced by lack of adequate financing and inefficient use of resources. Insufficient access to care and the existence of financial barriers are among the main causes of this problem ().

Barriers to access, exclusion, and changing needs are major challenges for health systems, which the reform and transformation processes undertaken in recent decades have not yet been able to fully surmount. In response to these problems, the Strategy for Universal Access to Health and Universal Health Coverage highlights the urgent need to expand equitable access to comprehensive, quality services in the Region (). Its first strategic line identifies the following key elements to guide the changes needed in the organization and management of health services in order to move towards universal health:

  • Strengthen or transform the organization and management of health services through integrated health services networks.
  • Move toward designing comprehensive, quality, universal, and progressively expanded health services.
  • Increase investment in the first level of care, as appropriate, in order to improve response capacity.
  • Increase employment options, especially at the first level of care.
  • Improve the availability and rational use of medicines (including vaccines) and other health technologies.
  • Facilitate the empowerment of people and communities.

This section describes the basic elements and orientations of each key area, as well as the progress made and the challenges for implementation.

Expanding equitable access to comprehensive, quality services

The available data show some significant improvements, although results vary from country to country. A comparison of data on health insurance coverage, use of preventive services, and barriers to access to health services for Chile, Colombia, Mexico, Peru, and the United States reveals gains in health service coverage and access in most of these countries of the Region, together with reductions in inequalities between income quintiles. Between 2014 and 2015, the level of health insurance coverage was quite high for these countries, with averages of approximately 98% in Chile, 95% in Colombia, 86% in the United States, 80% in Mexico, and 73% in Peru. Despite these high average percentages, however, insurance coverage among the poorest households was much lower than among the wealthiest ones, especially in the United States (–14 points) and Peru (-12 points). More importantly, these high insurance coverage levels did not always coincide with levels of health service use or with the percentage of households reporting access barriers, which demonstrates once again that coverage, particularly insurance coverage, does not in and of itself ensure access to services. For example, data on use of preventive care services between 2011 and 2015 show varying percentages of use among the five countries, with national averages of 98% in the United States, 75% in Colombia, 76% in Mexico, 24% in Chile, and 15% in Peru. Colombia and Mexico showed the greatest progress, with increases, respectively, from 60% to 75% between 2010 and 2015 and from 73% to 76% between 2012 and 2014. In Colombia, Mexico, and Peru, the use of preventive services was lower among the population in the lowest income quintiles. These inequalities were even more evident in Colombia, where the gap between the richest and the poorest households was almost 20 percentage points in 2015. In Chile, an inverse relationship was observed, while in the United States there was no clear pattern of disaggregation. The data for Canada, Colombia, and Peru also show marked geographic inequalities in the use of preventive services, with no noticeable improvements between 2005 to 2015. In 2015, the use of preventive services varied between 44.4% and 81.3% across the geographic subdivisions of Canada, between 17.45% and 83.49% in Colombia, and between 0.4% and 6.5% in Peru. With regard to the percentage of households that reported access barriers, the average between 2014 and 2015 was 37% in Peru, 19.9% in Mexico, 6.8% in Chile, 2.3% in Colombia, and 1.9% in the United States. The proportion of households that reported barriers was markedly higher among poorer households than among richer ones in Peru and Mexico, in particular. It is worth noting that inequalities have declined in the majority of these countries for all the indicators analyzed.

In contrast with the situation of preventive care, the majority of the countries in the Region have achieved universal coverage (100%) or near universal coverage (≥93%) of maternal and child health services (). Data disaggregated by income quintile for Bolivia, Colombia, the Dominican Republic, Haiti, and Peru show a downward trend in inequalities, although differences between the poor and the rich persist. For example, in Peru the difference in maternal care coverage among women in the highest income quintile and those in the lowest income quintile shrank from 60 to 12.8 percentage points for prenatal visits and from 80 to 30 percentage points for institutional births (). Nevertheless, the coverage of these services continues to be much lower among the poorest women. In Peru in the period 2005–2015, 69% of the poorest women gave birth in a health care institution, compared with 99% of the wealthiest women ().

As for access to immunization, major improvements have been recorded. The majority of countries have vaccination coverage rates of 93% to 100% for the diphtheria/pertussis/tetanus triple vaccine (DPT), with the exception of Ecuador, Guatemala, Haiti, and Panama, which have less than 80% coverage. Data on inequalities for Bolivia, the Dominican Republic, and Haiti show not only an increase in overall DPT vaccination coverage per year, but an even larger taking place in the poorest segments of the population, which is indicative of an improvement in equity of access ().

Data on the percentage of the population reporting barriers to health service access show marked geographic inequalities and limited improvements over time. In 2013, 16.9% of the population in Canada reported barriers to health service access, compared with 16% in 2005. The variation between geographic subdivisions was 11.48% to 20.6%. In Peru, it was 1.9% to 29.8% in 2015, while in Colombia, 11.5% of the population reported economic access barriers in 2011, compared with 42.3% in 2007. Data from the United States indicate that from 2010 to 2014 there was a reduction of 10% to 20% in the number of adults (19-64 years of age) who reported not having access to medical care because of its cost (). Data for the Region of the Americas indicate that avoidable mortality declined between 2010 and 2014 in Anguilla, Belize, Brazil, Costa Rica, Ecuador, Monserrat, Paraguay, Peru, and Suriname, although there were significant differences between countries.

Transforming the organization and management of health services through the development of health care models that focus on people and communities

The model of care provides the strategic orientation and general features of the organization of a health system, the purpose of which is to meet the needs of individuals, families, and communities. The model of care finds expression in several dimensions: the specification of what health services and benefits are guaranteed (the what), the way in which services are organized and managed in order to provide care (the how and where), and how the resources to finance the services are allocated. Accordingly, the model of care brings together the functions of the health system (Figure 1). It also incorporates the life-course, gender, human-rights, ethnic, and intercultural perspectives, and it promotes active social participation and extramural and intersectoral action.

Figure 1.Functions of the health system and the model of care

Source: Pan American Health Organization. Versión preliminar del informe Expandiendo el Acceso Equitativo a los Servicios de Salud: recomendaciones para la implementación y la acción. Washington, D.C.: PAHO; 2015.

The countries of the Region have moved forward in the development of a model of care with these characteristics (Table 1) and are in various stages of implementing the model. Nevertheless, the majority of countries continued to a biomedical model that should be no longer used.

Table 1. Overview of health care models with ethnic and intercultural perspectives

Country Structure Model of care or of program Standards and technical guides Reported experiences
Bolivia Vice-Ministry within the Ministry of Health and Sports SAFCI Program – family, community, and intercultural health model Strategic guidelines for traditional medicine and interculturalism in health Experience of Potosí
Chile Indigenous Health Care and Interculturalism Unit Comprehensive family and community health care model with an intercultural component Standards that include appropriate equipment, architectural modifications, protocols for referral and coordination between traditional and conventional medicine practitioners Makewe and Nueva Imperial hospitals, Boroa Filulawen center
Ecuador National Directorate for Intercultural Health within the Ministry of Health Comprehensive family, community, and intercultural health care model Guidelines that encourage health promotion from the perspective of diverse world views, culturally appropriate services, and coordination between the health system and traditional and ancestral wisdom Guamaní health area
Guatemala Indigenous care unit within the Ministry of Health Inclusive health model Standards developed in keeping with the inclusive model, including referral and counter-referral between different practices Municipal district of Nahuala
Mexico Directorate of Traditional Medicine and Intercultural Development Health and Nutrition for Indigenous Populations national action program Intercultural integration policies, use of traditional medicine Program for comprehensive hospitals with traditional medicine in the State of Puebla, health units under the national program
Peru National Center for Intercultural Health (CENSI), National Institute of Health/ Ministry of Health Comprehensive family- and community-based health care model Guidelines for intercultural action, including cultural diversity, traditional medicine, and integration into the system Culturally sensitive maternity care experience in in Ayacucho

In order to move towards a people- and community-centered care model, the strategy calls for an increase in the response capacity of the first level of care within an integrated health services network (IHSN) based on the primary health care strategy ().

PAHO has outlined the essential attributes and the domains that should be taken into account when designing and implementing such a network. Moving to an IHSN means that the work of health service providers must be guided by health priorities. Regulation and governance mechanisms are also needed to ensure coordination among the providers in the network and balance and linkage among national and local authorities, civil society organizations active in the area in question, and the population served by the network (see Chapter 1, Topic 4, Stewardship and Governance) ().

If a network of services is to operate efficiently, the services must be organized in a particular way. Disease prevention and health promotion services should be emphasized and ambulatory health care services should be given preference over hospital services. The first level of care should include groups of service providers who work in interdisciplinary teams and are linked to other institutions that provide specialized hospital-based and ambulatory care services. The first level should also have the capacity to coordinate care for users of the network of services. Evidence indicates that services are increasingly being transferred from hospitals to specialized ambulatory care or community-based services. It will not be possible to set up efficient networks without making changes in how health care processes are designed and delivered. Special attention should be paid to changes in the organization and management of hospitals so that they contribute efficiently to the objectives of the network, since hospitals, although they serve small segments of the population, are necessary for the delivery of highly complex and specialized services. Hospitals also account for the highest proportion of spending within health systems and are the focus of public attention and political concern. Current trends suggest that hospitals that function within an integrated network tend to need fewer beds, will make more intensive use of technologies and human capacities, and will orient their activities more towards ambulatory care. At the same time, efficiency and clinical outcomes will improve if high-complexity centers are developed ().

The problems currently besetting hospitals (such as excess demand in emergency rooms and long waits for elective procedures) will only worsen if changes are not made in the design and operation of the network as a whole, especially if the response capacity of the first level of care is not increased. In other words, it is impossible to have an IHSN without hospitals, but hospitals will not be sustainable if they are not part of an IHSN.

Higher priority must be attached to health promotion and disease prevention services that are oriented towards the coproduction of health, with a strong focus on ambulatory care and the incorporation of intercultural and gender features. It is also necessary to create opportunities for intersectoral action in the community and, sometimes, to seek opportunities for synergy between public and private actors ().

In order to put in place an efficient network, it is necessary to ensure the availability of human resources, medicines and health technologies, financing and incentives aligned with the objectives of the network, and capacities for leadership and governance. These elements will be examined in this and the following sections.

Internationally, there is evidence of the importance of reorienting health care services as described above (). In the Region, the key strategies being applied in the transformation of health care models include: investing in primary health care centers, establishing family health, developing the workforce for primary and community-based health care, developing multidisciplinary teams in the community, establishing community outreach services, investing in specialized care for older persons (including support for home care), integrating mental health care into primary care, and promoting the use of new technologies to provide treatment and manage care in remote communities.

The extent to which care models have been reoriented and transformed varies, however, ranging from reorganization of the entire network of services (Box 1) to a shift designed to address specific problems or diseases (for example, care for persons with chronic diseases and older adults and mental health care – see Box 2) or strengthen the first level of care without an IHSN approach ().

Box 1. Development of Integrated Health and Social Service Centers in Quebec, Canada ()

The Province of Quebec, Canada, has been applying a long-term strategy to overcome fragmentation in the way health care is organized and provided across its 17 administrative regions. To that end, it has established a modality of care that formally integrates the financing and delivery of health and social services. In 2004, health sector reforms reorganized the model of care into 90 integrated health and social services centers (CISSS, from the French Centres intégrés de santé et de services sociaux) that provide services to specific local populations. The emphasis has been placed on accessibility and continuity of preventive care, as well as on curative services for groups in more vulnerable conditions.

CISSSs provide PHC-based health and social assistance services through “autonomous” family medicine groups. They encourage a multidisciplinary approach, enhancing the role of nurses and public health workers and empowering community groups, including citizens committees and representatives of the community. Among the principal interventions carried out are the following:

  • Partnerships of community nurses with hospital emergency rooms to monitor and manage frequent users in community environments in order to reduce hospital readmissions;
  • Investment in education and training in comprehensive care to support joint action and serve vulnerable groups in the community; and
  • Interdisciplinary teams comprising health and municipal government personnel to support older persons in their homes through an approach emphasizing independent living and adapted dwellings.

The key challenges identified for the development of new approaches to care in Quebec included population aging and related new health problems, increased inequalities between social classes, difficulties in controlling expenses, and political issues related to financing of long-term public health care. Integration proved problematic because of competition among professional groups and autonomous service providers. Lack of preventive care remains a deficiency in the way in which care is provided.

Key lessons for the future of integrated health and social services centers in Quebec include:

  • Expand the functions of nurses at the clinical and community levels.
  • Integrate other health professionals to support family doctors in the clinical environment.
  • Ensure monitoring of the delivery and quality of private medical care, especially for the elderly.
  • Increase citizen participation in the management and organization of first-level care centers, and the participation of users in planning.
  • Improve the integration of curative and preventive approaches in the practice of family medicine.

Box 2. Improving the quality of care for chronic diseases in the Caribbean (Anguilla, Antigua and Barbuda, Barbados, Belize, Grenada, Guyana, Jamaica, Saint Lucia, Suriname, and Trinidad and Tobago) ()

Demonstration projects using the chronic care model have been carried out across the Caribbean in 142 health centers, with the participation of 40,000 patients. The goal of these projects is to boost the capacity and skills of local health teams to better manage care for people with diabetes. The specific focus of these projects is to encourage the participation of patients, their families, and the community through the introduction of the PAHO Chronic Care Passport. The aim is to support education on the disease itself and on self-management. The preliminary results show reductions in glycosylated hemoglobin (HbA1c) levels, a substantial increase in the number of people who receive preventive care (for example, nutritional counseling and examination of feet and vision), and improvements in quality-of-care indicators.

One of the non-delegable responsibilities of the network of services is to ensure the quality of services. Quality is an inherent attribute of–and a requirement for–universal health. In order to achieve equitable access to comprehensive quality services, a systemic approach is required, spearheaded by the health authority in the exercise of health system stewardship (see Chapter 1, Topic 4, Stewardship and Governance). At the health services network level, interventions are aimed at ensuring responsive care that meets people’s needs and expectations. Numerous initiatives have been launched In the Region to ensure quality in the delivery of services (Table 2).

Table 2.Summary of initiatives to address quality in health systems

Country Support structure National policy Experience reported
Ecuador National Department for Quality Assurance of Health Services, National Agency for Quality of Health Services and Prepaid Medicine (ACESS) Development of a culture of quality; quality control of services; support for users of the system and assurance of effective operation of health services Plan for accreditation of 44 hospitals
El Salvador National Quality Management Unit of the Comprehensive and Integrated Health Services Networks (RIISS) RIISS quality management system Specialized pharmacy project
Honduras Quality management unit of the Ministry of Health Saving Lives with Quality program Reduction of neonatal deaths at Mario Catarino Rivas Hospital Implementation of safe surgery
Mexico General Directorate for Health Quality and Education National Strategy for the Consolidation of Quality in Health Care Establishments and Services Evaluation of the implementation of the Comprehensive Health Quality System (SICALIDAD)
Peru General Directorate for Quality in Health, National Health Authority Health quality management system Protection of health rights in Peru: experiences arising from the oversight role of the National Health Authority

Moving towards the design of comprehensive, quality, universal, and progressively expanded health services

Health systems should be capable of defining the benefits that are going to be made available to the populations they serve. In so doing, they should seek to build in a dynamic process of progressive expansion aimed at ensuring that an increasing number of health problems can be resolved through the incorporation of new knowledge and resources, involving and making more innovative and creative use of public, private, and social security resources to reduce fragmentation, facilitate economies of scale and ensure an integrated response. This definition of benefits is key in order to realize the aspiration of ensuring equitable access to comprehensive, quality, people- and community-centered health services ().

In order to move forward in this area, one of the most essential tasks is to decide on a method for prioritizing services and benefits. The objective is to offer communities and populations a specific set of services designed to improve their health and well-being ().

The question of how to prioritize services, and thus design basic national packages of health services and benefits, has been widely debated for many years in the Region of the Americas (). Historically, the debate has centered around the strategic purchase of health services through a continuous search for the best interventions. The countries of the Region are currently at different stages of the process of specifying health services and benefits; they also differ in terms of the way the right to health is formulated (see Table 3 and Boxes 3 and 4).

Table 3. Specification of services and benefits in selected countries of the Region of the Americas ()

Country Name of benefit package Year implemented Population covered (%) Relevant legislation Regulatory entity Quantity and type of services
Argentina Compulsory Medical Program (PMO) 1995 52% Acts 23660 and 23661 Department of Health Services, Ministry of Health All levels of care

Broad and explicit list

Some criteria for coverage

Brazil National List of Health Services and Activities (RENASES) 2011 100% Act 8080
Act 8142 on the Unified Health System (SUS)
Ministry of Health, Health councils (national, state, and municipal) Primary care services

Urgent and emergency services

Psychosocial services

Specialized health care services

Public health surveillance services

Chile Explicit Health Guarantees (GES) 2005 100% Act 19966
Act 18933
Health authority, Ministry of Health Free first-level services

Secondary and tertiary level services for 80 health problems to date

Coverage guides and medicines list

Guyana Guaranteed Package of Public Health Services 2008 100% Ministry of Health All levels of care Includes medicines list
Peru Essential Health Insurance Plan (PEAS) 2009 Workers covered by Social Security and by public insurance Act 29344 on Universal Insurance Health authority, Ministry of Health First, second, and third level with care for 50 health problems selected on the basis of the burden of disease
Uruguay Comprehensive Health Care Plan (PIAS) 2008 100% Decree 465/008 of 10/2008 National Health Board (JUNASA), Ministry of Public Health Comprehensive health programs and catalog of benefits:

  1. Medical care modalities
  2. Medical specialties, other professionals, and technical personnel for the management and the recovery of health
  3. Diagnostic procedures
  4. Therapeutic and rehabilitative procedures
  5. Oral health
  6. Medicines and vaccines
  7. Medical transportation

Adapted from: Leguiza Fondos J, et al. Análisis comparativo de conjuntos de prestaciones que brindan los sistemas de salud en las Américas y el Caribe. (Comparative analysis of packages of services provided by health systems in the Americas and the Caribbean). Washington, D.C.: PAHO; June 2012 (unpublished document).

Box 3. Development of a Comprehensive Health Services Plan in Uruguay ()

Uruguay’s Comprehensive Health Care Plan establishes overall guarantees for an integrated national health system and has sought to strengthen governance and the regulatory process. Launched in 2007, the Plan’s key innovation was the creation of a catalog that sets out an exhaustive list of benefits, including 1,600 technical procedures related to diagnosis and nearly 3,000 procedures related to therapy and rehabilitation, oral health, vaccines, medicines, and means of transportation. In 2008, the Plan was expanded through the addition of a set of existing public health programs, such as support for self-care.

The list is updated on the basis of scientific evidence and changes in prevailing epidemiological conditions, with support from a group of experts. A rigorous process is followed that involves examining a set of impact criteria and the evidence base and determining whether improvements are justified in terms of healing and better quality of life. After the list is developed, a working group classifies and considers the efficacy of treatment and places the interventions in priority categories.

The catalog laid a foundation for establishing contracts for management of the model of care with public and private providers (a first round in 2008 and a second in 2012), including sanctions in the event of non-performance. The National Fund (which is income tax-based) negotiates rates and incentives with a view to promoting universality of access and quality of care, with professional incentives linked to changes in the model of care and quality. Payments are results-oriented, which allows for greater technical and administrative autonomy and flexibility for providers.

The main challenge to the Plan’s success has been to ensure sustainable care that is distributed in a fair and ethical manner. The strategy for communicating with citizens has been essential in order to help people understand that a country has limited resources and has demonstrated transparency in the development of its system of guarantees. The main principles guiding implementation include: transparency in decision-making, promotion and communication of results, management of public and professional opinion, and social participation.

Box 4. Implementation of Explicit Health Guarantees (AUGE) in Chile ()

The AUGE reforms in the Chilean health system have sought to support the development of a more integrated health system and to overcome problems related to financing, in particular high levels of private financing, and segmentation in the delivery of services. The reforms include new insurance schemes for low-income people (FONASA, which covers 7%, and ISAPRE). FONASA is geared towards reducing premiums and developing healthier populations among the poorest groups, while ISAPRE focuses on the higher-income brackets.

The basic principle guiding AUGE has been the integration of public and private financing in order to create a service with explicit guarantees, comprehensive regulation, and stronger management that promotes integrated models of care through integrated public and private networks. It includes 56 guarantees aimed at addressing chronic diseases and population aging, with a focus on strengthening primary health care, in terms of access, equity, quality, and financial protection. The latter is important in order to prevent the package of benefits from becoming a regressive tax.

The process of developing the AUGE reforms was reportedly highly political, but it took account of external consultation processes by the Ministry of Health aimed at reaching agreement on the basis for guarantees and implementation to be applied progressively. As a result, there was a large increase in financial coverage for people with insurance.

Curiously, AUGE has been insufficiently utilized, as people have maintained dual coverage, and prices of the previous coverage have declined. AUGE has improved diagnosis and treatment times, but has also been associated with an increase in administrative bureaucracy. The successes reported include more timely care and some progress in changing the model of care to promote public health and address chronic diseases. Unexpected negative impacts include “patient poaching” by providers prompted by payment system incentives. These problems should be addressed by switching to payment of incentives based on episodes of care, perhaps in the form of bundled payments. Chile continues to grapple with problems of segmentation and inequality, but has made important progress in promoting citizens’ health rights.

Prioritizing investment in the first level of care

In order to expand access to health services, it is necessary to prioritize investment in services at the first level of care in order to boost their response capacity. To do this, new resources are needed in the majority of the countries of the Region. Funding for such investment cannot be obtained only by seeking efficiencies or reallocating resources from hospitals to the first level of care, since, generally speaking, spending on public health remains insufficient (see Chapter 1, Topic 5, Health Financing in the Americas). Although most countries lack information systems that would make it possible to measure the increase in investment at the first level in financial terms, in recent years several countries have made significant progress in the development of their first level of care, as is evident from the information in Table 4.

Table 4. Experiences in primary health care as a means of moving towards universal health

Country Model of care and management Composition of the health team Functions Levels of system management
Bolivia “My Health” program within the framework of the government policy on family, community, and intercultural health (SAFCI). Operates through local health centers and higher-complexity centers that come under the responsibility of municipal governments Physician, nurse, nursing auxiliary Medical care at the local health center, family visits, and social management Ministry of Health-regulation and oversight of the entire system
 
Departmental governments and health services and municipal governments, which are responsible for the first and second levels of care
Brazil The Unified Health System (SUS) of Brazil includes health activities and services provided by public federal, state and municipal agencies or institutions. Territorial teams serving 800 to 1,000 families: general practitioner or family medicine specialist, nurse and nursing auxiliary, community health workers, dentist and oral health assistant Prevent and control diseases, injuries, and health risks; expand access to health services and health promotion and disease prevention interventions; management of health determinants; and strengthening management of the SUS at all levels of government Three levels of government (federal, state and municipal)
 
Complementary participation by private enterprise recognized
Costa Rica Costa Rican Social Security Fund (CCSS), public health insurance that includes comprehensive medical care, cash benefits and social services provided by decentralized institutions. The Ministry of Health oversees the performance of the essential public health functions and exercises sectoral leadership. National Council of the Health Sector. Basic comprehensive health care teams, distributed across 103 health areas (3,500-7,000 inhabitants): general practitioner, nursing auxiliary, medical records assistant, and comprehensive health service technician Disease prevention and health promotion, recovery, and maintenance; care for prevalent and emerging health conditions Ministry of Health, Costa Rican Social Security Fund, and decentralized institutions: National Insurance Institute, Costa Rican Institute of Water Supply Systems and Sewerage Systems, Alcoholism and Drug Dependency Institute, Costa Rican Institute for Research and Teaching on Nutrition and Health, National Health Council
Cuba Family Doctor and Nurse model, oriented towards health promotion, prevention and curing of disease, and rehabilitation at all health care levels Basic health teams: physician and nurse responsible for the health of the population they serve Comprehensive health care; educational research, managerial, and environmental activities Centralized system under the Ministry of Health, linked with government entities at the national and local level: National Assembly, Council of State, Council of Ministers, assemblies at the municipal and provincial level
Ecuador Comprehensive care model of the National Family, Community, and Intercultural Health System (MAIS-FCI) Basic health care teams: physician, nurse, psychologist, dentist, and auxiliary Promotion, prevention, treatment, rehabilitation, and home visits Integrated, decentralized, territorial, and participatory management, with transfer of competencies and resources according to MAIS-FCI requirements
 
Intersectoral coordination, integrated action at territorial level
 
Government results-based management (RBM) tool
El Salvador Comprehensive Basic Health Systems (SIBASIs), with interventions by public and private providers Health promotion, disease prevention and cure, and rehabilitation, focused on the individual, the family, the community and the environment 380 community family health teams and 28 specialized teams in 53% of low-income municipalities Comprehensive health care, decentralized management, delivery, and financing of health services and social participation Three levels:

  • Highest: Ministry, regulatory entity
  • Regional: regional directorates (SIBASI technical and administrative level), resource management
  • Local: SIBASI operational network and hospitals
Nicaragua Family and Community Health Model (MOSAFC), with three components: service delivery, management, and financing
 
Health networks include three levels of care and comprise community, public, and private establishments
Family and community health teams: physician, nurse, nursing auxiliary, basic sanitation technicians, and community health workers Comprehensive and integrated approach to education, promotion, prevention, treatment, and rehabilitation with emphasis on vulnerable groups and a life-course approach to care These actions are carried out through a network approach, actively involving community agents such as midwives, community health workers, and family, community, and life councils

Increasing employment options, especially at the first level of care, with attractive labor conditions and incentives, particularly in underserved areas

The expansion of equitable access to comprehensive, quality services in order to advance towards universal health requires significant changes in the management of human resources for health. A key element, as is noted in the strategy, is the expansion of employment options, especially at the first level of care, with attractive labor conditions and incentives, particularly in underserved areas. This intervention should be accompanied by the development of interdisciplinary teams at the first level of care. Interdisciplinary teams are needed to promote innovation, community participation and the empowerment of people with regard to health, intersectoral work, and the adaptation of specific work contexts to the health needs and preferences of communities.

An overall shared mission is imperative, with broad common goals and responsibilities, regulations for quality and safety of care, a mechanism for merit-based recruiting and hiring, and comparable labor conditions. Part of this mission should be to ensure the delivery of a set of services and programs and the existence of standards, work processes, treatment protocols, a management and coordination model, and accountability mechanisms.

Various countries have launched initiatives aimed at addressing the challenge of human resources for universal health. For example, in Peru, candidates for public positions, admission to second professional specialization programs, and government fellowships for basic or advanced studies are required to serve in rural or marginalized urban areas under a Ministry of Health initiative known as SERUMS (Servicio Rural y Urbano Marginal de la Salud). The initiative has boosted the number of physicians working in rural areas from 2,500 in 1999 to almost 9,000 in 2013 (). In Brazil, the Mais Médicos program is an initiative designed to improve the coverage of physicians at the first level of care, especially in rural and other underserved areas. The program includes medium- and long-term planning policies aimed at reorienting undergraduate education, a compensation policy with special incentives (for both Brazilian and foreign physicians), and an international collaboration agreement with the Government of Cuba. Thanks to an influx of 14,000 additional physicians at the first level of care during 2013, the program has improved the availability of medical professionals in the most underserved areas, especially rural areas. In Chile, the Health Careers System for physicians includes a training phase of up to 9 years in which the professionals are required to work at the first level of care in order to qualify for later specialization. Chile also has a remuneration policy that encourages health workers to work in rural and underserved areas. This policy provides special supplements for personnel who work in isolated areas or areas with high cost of living, with hardship pay for personnel working in very isolated or remote locations or performing difficult jobs at the first level of care in vulnerable or geographically isolated areas (). Uruguay is implementing its National Rural Health Program, which addresses three critical needs: better access to health services for rural populations, access to comprehensive health services (provided by a highly trained and committed interdisciplinary team), and assurance of continuity of care throughout the health care process. This program has made it possible to improve access to health care for residents of rural areas through interdisciplinary care teams ().

Improving the availability and rational use of medicines (including vaccines) and other health technologies

The aim in seeking to improve equitable and sustainable access to medicines and other safe, effective, high-quality, and cost-effective essential health technologies is to prevent, alleviate, diagnose, and treat health disorders, all of which are vital to progress towards access to universal health in the Region.

Access to medicines can be facilitated through solid and holistic management of the supply chain. Such management should ensure the integrity of the chain and the timely availability of products. A critical area is demand forecasting. Efficient supply management should include good procurement mechanisms, since such mechanisms have a significant impact on price. Procurement methods that favor competition and concentrate the purchasing power of public funds tend to reduce prices. By pooling demand across the public sector, national joint purchasing mechanisms are improving the ability of the public sector to negotiate and secure better prices. Similar results have been observed when demand is pooled at the international level. The most noteworthy examples are PAHO’s Revolving Fund for Vaccine Procurement and Regional Revolving Fund for Strategic Public Health Supplies, also known as the Strategic Fund. In 2016, 30 countries of the Region signed the agreement to participate in the PAHO Strategic Fund, through which they can access more than 150 essential and strategic products for their health programs. In 2015, purchasing through the fund exceeded US$ 70 million and yielded savings of 30% to 80% in drug costs to countries, thanks to procurement through international competitive bidding and economies of scale made possible by pooling demand from many countries. With regard to joint negotiating schemes, a noteworthy experience is the one being spearheaded by the MERCOSUR and UNASUR countries, which in 2015 formed a joint committee to negotiate with multinational pharmaceutical companies on the prices of a group of high-cost drugs. Through a transparent and collective mechanism shared among countries, and with technical support from PAHO and the use of the mechanism of the fund, countries have sought to improve the availability of essential medicines for the treatment of HIV/AIDS and hepatitis C. Sizeable reductions in the price of insert (for HIV/AIDS) have been achieved, as much as 83% in some countries. Countries continue to work jointly with PAHO to obtain better terms for the purchase of inputs for the management of hepatitis C.

With regard to the general availability of blood in a country, the rate of whole blood donation per 1,000 population is a good indicator. This rate is 32.1 donations per 1,000 population in high-income countries, 7.8 in middle-income countries, and 4.1 in low-income countries (). In 2014, the average donation rate in Latin America and the Caribbean was approximately 14.84 per 1,000 population; 45.39% of those donations came from unpaid volunteer donors, while 54.52% came from replacement donors. Although the donation rate per 1,000 population has fallen slightly in recent years (15.25 donations per 1,000 population in 2010, for example), the percentage of voluntary donations has risen steadily, climbing from 41.4% in 2010 to 45.39% in 2014. However, the high percentage of replacement donors represents an inequality that continues to affect blood availability.

Access to medical radiology services depends not only on the availability of appropriate, quality medical devices. It also depends on the effective integration of such services into the health services network and on their rational use.

Rapid technological progress is enabling the development of innovations in health care planning and delivery methods. There has been significant progress in the use of remote monitoring applications for the management of diseases such as diabetes and chronic obstructive pulmonary disease (COPD). This progress has been possible thanks to the availability of a growing number of mobile health applications. When effectively deployed, these approaches have shown that they can facilitate self-care and support continuous monitoring of symptoms in order to facilitate early intervention. E-health technology is now widely used in the Region as a means of increasing access to services, especially in rural and remote localities, and it can also be used by health care providers to facilitate coordination of care () (Box 5).

Box 5. Strengthening the first level of care through the use of new technologies in Panama ()

New technologies have been used strategically to strengthen the first level of care in Panama through the development of electronic health care records. These records serve as tools for decision-making about diagnosis, management of symptoms, and follow-up as part of the disease treatment and management process (Ministry of Health program). The synchronization of health records has helped to improve communication among health care professionals and providers. Information systems and the exchange of data facilitate clinical management, evaluation, and follow-up have helped to improve the allocation of limited resources in places where human resources or physical infrastructure were limited.

The development of telemedicine has also permitted remote management of patients (development of virtual hospitals in local communities), support for better management of symptoms, and promotion of self-care. Potential obstacles to their application include availability of human and financial resources to support the development of telemedicine, as well as cost and availability of the technological infrastructure itself. Both health professionals and service users have shown resistance to such changes. New skills are required, which means that new education and certification programs may be needed.

Facilitating the empowerment of people and communities so that they are more knowledgeable about their health situation and their rights and obligations and can make informed decisions about their health

The active participation of individuals and communities has been a fundamental principle in the successive strategies of WHO and PAHO, which have long emphasized people-centered care. The Alma-Ata Declaration, for example, recognized community participation as a key ingredient for strengthening health systems based on primary health care ().

In order to advance towards universal health, health systems must develop programs, interventions, and strategies to support both processes that empower people and processes that strengthen community participation in health.

A review of the evidence suggests the following four key strategies for involving individuals, their families, and caregivers:

  1. Self-management of health and health conditions: Includes support for the development of knowledge, abilities, and confidence to manage one’s own health (self-care), care for specific disorders, and recovery from an episode of ill health.
  2. Shared decision-making: Includes support to enable individuals to make decisions about their health, so that they can weigh various options (including the option not to take any action), think about risks and benefits, and consider how the available options mesh with their values and preferences.
  3. Actions among equals: Support for people in giving and receiving assistance from other people in similar circumstances, on a basis of mutual and shared understanding.
  4. Support for families and caregivers. The aim is to develop knowledge, skills, and actions so that people can take care of themselves and others (). Caregivers play a fundamental role in community health. Caregiving is considered a capacity for service and a human ability to care for the health of the community. It is therefore work that should be socially recognized and measured and valued in the health system. It should also be well paid if it is to cease to be considered an inescapable duty to be performed by women ().

Community participation in planning and goal-setting can help communities examine the factors underlying health problems and raise community awareness and can lead to community-led approaches to key challenges. For example, in Peru, community awareness-raising has been used as a strategy for promoting multisectoral collaboration and involving marginalized communities in decision-making about their health care ().

Community awareness-raising through education and participation in learning encounters and activities can help build stronger social networks and foster greater integration. Such measures work well when they focus on a specific health problem of mutual interest and when conversations and activities are culturally sensitive, as in the example described in Box 6.

Box 6. Promotion of health education and community participation in the city of Tunia, Colombia ()

In Colombia, 50% of families with young children live in the country’s poorest areas. Living in poverty generates a negative cycle of illness, poor mental health, lack of educational achievement, and reduced ability to work. Investing in early childhood development was therefore essential. However, traditional assistance programs tended to be paternalistic, charity-based, and ultimately unsustainable.

The city of Tunia, Colombia, has introduced a public policy on child health that aims to create a culture of care and protection for children from the moment of conception to the age of 5 years, upholding their rights and nurturing their development in order to assure them of a better future. A key part of the approach is promotion of community engagement and involvement, health education, and a new approach to health care among the residents of the city.

The approach includes the training of administrators to support activities relating to health education and nutritional counseling, family life, parenting, and promotion of community leadership. The approach to families and family life has encouraged the development of work skills, continued learning, and wise use of family finances. Approximately 355 family leaders have received training from 710 agents, which has had an impact on 4,289 vulnerable families with young children. The results have made a real difference, as can be seen from the changes reported between 2012 and 2014:

  • The proportion of pregnant women with appropriate weight and health rose from 33% to 86%.
  • The proportion of children weighing 3,000 g or more at birth increased from 60% to 65%.
  • The proportion of young children with chronic malnutrition decreased from 15% to 5%.
  • The proportion of fathers present at the birth of their children rose from 92% to 96%.

Care provided by the community through the collaboration of volunteers or community health workers as partners in care can achieve numerous objectives, including enhancing the legitimacy of and fostering trust in health care services, helping to strengthen the first level of care, encouraging learning among equals, and bolstering access to care and local support. For example, the development of “customer ownership” in the health system of Nuka, Alaska, led to investments that promoted universal access to community health associations and to the development of community partnerships that have had a profound and lasting impact on the improvement of population health ().

Organized groups of people who represent the opinions of people at the local or national level offer the opportunity to develop democratic responsibility among health services and the local communities, strengthening governance and promoting advocacy. For example, in Colombia the New Paradigm project encouraged people with spinal cord injuries to get together regularly to discuss their health care issues in collaboration with health professionals. This approach has enabled learning among peers and helped to encourage and build trust ().

The development of community empowerment strategies helps protect people’s right to health and promotes responsibility-sharing between the population and health care providers. Through the creation of transparent, respectful, and responsible relationships among communities, providers, and decision-makers, this approach helps to generate the necessary conditions for people to take more responsibility for their health and lifestyle decisions and better address the social determinants of health. This contributes to informed decision-making, better knowledge of health, promotion of self-determination, and greater involvement by people in decision-making and in influencing matters that affect their lives and the lives of their communities ().

Conclusions

This topic has explored various necessary and complementary elements for advancing towards access to comprehensive, equitable, and good quality health services. The agreements adopted by PAHO, the volume of available evidence, and technical cooperation tools constitute a solid support for the efforts of the health systems in our countries to achieve their objectives. In the preceding pages, we have endeavored to summarize each of these elements and to highlight some examples of progress in the countries of the Americas in recent years. While progress has been made, numerous challenges remain, and not all countries are advancing at the same rate. PAHO is convinced that access to comprehensive, equitable, quality health services can be achieved by following the recommendations in the universal health strategy and the technical documents that complement it.

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Reference/Note:

1 Estimate by the authors on the basis of available information from 38 countries of the Region that submitted reports in 2013 and 2014 to PAHO’s Health Information Platform for the Americas (PLISA).

2 Sources: Bolivia: Segunda Medición de Metas Regionales en Recursos Humanos, 2013; United States: Primary Care Workforce Facts and Stats No. 3, content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD; Canada: Scott’s Medical Database, 2015, Canadian Institute for Health Information. Note: the data for the United States are for physicians working at the primary care level.

3 Authors’ calculations based on data from Chile’s Ministerio de Desarrollo Social, Encuesta de Caracterización Socioeconómica Nacional, 2013 and 2015, data file and documentation: http://observatorio.ministeriodesarrollosocial.gob.cl/casen/basededatos_historico.php; Colombia’s Departamento Administrativo Nacional de Estadística (DANE), Encuesta Nacional de Calidad de Vida, 2010-2015, data file and documentation: http://formularios.dane.gov.co/Anda_4_1/index.php/catalog; Mexico’s Instituto Nacional de Estadística y Geografía (INEGI), Encuesta Nacional de Ingresos y Gastos de los Hogares, 2012 and 2014, data file and documentation: http://www.inegi.org.mx/est/contenidos/espanol/proyectos/metadatos/encuestas/enigh_211.asp?c=10748; Peru’s Instituto Nacional de Estadística e Informática del Perú, Encuesta Nacional de Hogares, 2010-2015, data file and documentation: http://iinei.inei.gob.pe/microdatos/; and the United States’ Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2014, data file and documentation: https://meps.ahrq.gov/mepsweb/data_stats/MEPS_topics.jsp?topicid=1Z-1. Data retrieved 21 Nov. 2016.

4 Based on calculations by the authors using data from Colombia’s Departamento Administrativo Nacional de Estadística (DANE), Encuesta Nacional de Calidad de Vida, 2012, 2014, and 2015, data file and documentation: http://formularios.dane.gov.co/Anda_4_1/index.php/catalog; Canada’s Statistics Canada, Canadian Community Health Survey, 2006-2013, data file and documentation: http://www.statcan.gc.ca/eng/survey/household/3226; and Peru’s Instituto Nacional de Estadística e Informática, Encuesta Nacional de Hogares, 2006, 2010, and 2011, data file and documentation: http://iinei.inei.gob.pe/microdatos.

5 Refers to the percentage of the population that had health problems and did not receive medical care due to lack of money, distance, time, difficulty in getting a medical appointment, or preference. Cultural, economic, geographical, and availability barriers are considered barriers to access.

6 Based on calculations by the authors using data from Statistics Canada, Canadian Community Health Survey (CCHS), 2005-2013.

7 Based on calculations by the authors using data from Colombia’s Encuesta Nacional de Calidad de Vida (ECD, 2012, 2014, 2015) and Peru’s Encuesta Nacional de Hogares, 2006, 2010, and 2011.

8 Calculations by the authors on the basis of available information for 38 countries and territories of the Region that reported data to the Health Information Platform for the Americas (PLISA) in 2010 and 2014.

9 Specialized ambulatory care services concentrate cost-effective technology and trained health personnel in specific areas for the management of complex cases and highly complex diagnostic and therapeutic procedures, such as imaging, endoscopy and laparoscopy, major outpatient surgery, dialysis, chemotherapy, etc. They also provide services for long-stay rehabilitation patients and services for community-based management of specific situations, such as care for mental health patients, care for dependent elderly persons, and initiatives for the care of other populations in conditions of vulnerability.

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